Background: Biliary mucinous cystic neoplasms (BMCNs) are uncommon neoplastic septated intrahepatic cysts which are often incorrectly diagnosed and have the potential for malignant transformation. Aim: The aim of this study was to assess the outcome of surgical resection of BMCNs. Methods: Data from a departmental and faculty registered prospective liver surgery database was used to identify patients who underwent surgery at Groote Schuur and the University of Cape Town Private Academic Hospitals for BMCN from 1999 to 2015. Standard demographic variables including age and gender were documented as well as detailed preoperative imaging, location and size, operative treatment, extent of resection, histology, post-operative complications using the Clavien-Dindo classification and long-term outcome. Results: Thirteen female patients (median age 45 years) had surgery. Eleven were diagnosed by computer tomography scan after investigation of abdominal pain or a palpable mass. Two were jaundiced. One cyst was found incidentally during an elective cholecystectomy. Five cysts were located centrally in the liver. Before referral three cysts were treated inappropriately with percutaneous aspiration or drainage and two were treated with operative deroofing. Six patients had anatomical liver resections and seven patients had non anatomical liver resections of which two needed ablation of residual cyst wall. One patient needed a biliary-enteric reconstruction to treat a fistula of the left hepatic duct. Median operative time was 183 minutes (range: 130-375). No invasive carcinoma was found on histology. There was no operative mortality. One surgical site infection was treated and one patient developed an intra-abdominal collection one month post-operatively. Two patients developed recurrent BMCN after 24 months. Conclusion: BMCNs should be considered in middle aged women who have well encapsulated multilocular liver cysts. Treatment of large central BMCNs adjacent to vascular and biliary structures in particular may require technically complex liver resections and are best managed in a specialized hepato-pancreatico-biliary unit.

Acute liver failure (ALF) describes a clinical syndrome resulting from severe liver damage and extensive loss of functional parenchymal liver mass triggered by various factors. Early recognition and initiation of specific therapy may improve outcomes and reduce the need for liver transplantation, a treatment modality not universally available in resource constraint areas. There is paucity of data describing this syndrome in Sub-Saharan Africa in children. Objective This study aims to retrospectively review and determine the clinical presentation, aetiology, complications & outcome of ALF in children admitted at the Red Cross War Memorial Children's Hospital (RCWMCH). Methods All records of children from 0 to 13 years admitted at the RCWMCH over the period from January 2005 to December 2016 with ALF were retrospectively reviewed, after obtaining ethical approval. Patients with pre-existing evidence of chronic liver disease were excluded. Demographic variables as well as clinical presentation and investigations were captured, with determination of outcomes at 3 weeks and 6 weeks of diagnosis. Results Study included 24 children., 16 females (66.7%) and 8 males (33.3%). Median Age was 15 months, with interquartile range from 5 to 28 months. Diarrhoea, jaundice, respiratory distress, hepatomegaly and encephalopathy were common clinical features. Aetiology was infection in 37.5 % of cases (n=9, 2 of whom had autoimmune hepatitis comorbidity) and hepatitis A was most common infectious cause (n=4, 44%). Causes were indeterminate in 29.2%. Two patients had autoimmune hepatitis without co-morbidity; Reye syndrome 12.5% and 17% had miscellaneous causes. Transaminases were raised to thousands in viral causes of hepatitis, with a low C reactive protein. INR >4 and Total Bilirubin>210umol/L were associated with death outcome (p=0.04 and p=0.03 respectively. Conclusion Viral hepatitis A is the leading infective cause of acute liver failure in this study cohort and 29.2% of cases were indeterminable. INR >4 and Bilirubin > 210umol/l were predictors of poor outcome. Follow up study is recommended to better understand clinical spectrum and outcomes of children with acute liver failure in this low resource setting.

Includes bibliographical references / Major bile duct injuries occur infrequently after laparoscopic cholecystectomy but may result in life-threatening complications. Few data exist about the financial implications of bile duct repair. This study calculated the total inhospital costs of operative repair in a cohort of patients who underwent reconstruction of the bile duct after major ductal injury sustained during laparoscopic cholecystectomy. A prospective database was reviewed to identify all patients referred to the University of Cape Town Private Academic Hospital between 2002 and 2013 for assessment and repair of major laparoscopic bile duct injuries. The detailed clinical records and billing information were evaluated to determine all costs from admission to discharge. Total costs for each patient were adjusted for inflation between the year of repair and 2013. Forty four patients (33 women, 11 men, median age 48 years, range 30 - 78) underwent reconstruction of a major bile duct injury. First time repairs were performed at a median of 24.5 days (range 1 - 3662) after initial surgery. Median hospital stay was 15 days (range 6-86). Mean cost of repair was R215 711 (range R68 764 - 980 830). Major contributors to cost were theatre expenses (22%), admission to intensive care (21%), radiology (17%) and specialist fees (12%). Admission to a general ward (10%), consumables (7%), pharmacy (5%), endoscopy (3%) and laboratory costs (3%) made up the balance. The cost of repair of a major laparoscopic bile duct injury is substantial due to prolonged admission to hospital, complex surgical intervention and intensive imaging requirements.

The aim of this study was to determine the safety and clinical effectiveness of 10Fr plastic biliary stents compared to uncovered self-expanding metal stents (SEMS) for palliative treatment of patients with inoperable malignant distal biliary obstruction in a public hospital in South Africa. Methods: From January 2009 to December 2013, 40 patients who were admitted to a tertiary academic centre because of distal malignant biliary obstruction were enrolled in a prospective randomised study. Patients were randomly assigned to receive either an uncovered SEMS or a plastic stent deployed through the biliary stricture during endoscopic retrograde cholangiopancreatography. Results: Patient survival time in the two groups did not differ significantly (median: SEMS - 114 days; plastic - 107 days) (p=0.181). Stent failure was more common in the plastic stent group (7/19 vs. 1/20) (p=0.043). The results became significant after 6 months of follow up. There was no significant difference between the two groups in the incidence of serious adverse events. Conclusions: SEMS had a longer duration of patency than plastic stents, which favours their use in the palliative treatment of patients with biliary obstruction due to distal malignant biliary obstruction.

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Thesis (Ph.D.)--Murdoch University, 2008. / Thesis submitted to the Faculty of Health Sciences. Includes bibliographical references (leaves 184-208)

Thesis (M.D.)--Yale University, 2007. / Includes bibliographical references.

<p>Hydrogen sulfide (H₂S) is an important modulator of many aspects of digestive function, both in health and disease. Colonic tissue H₂S synthesis increases markedly during injury and inflammation and contributes to resolution. Some of the bacteria residing in the colon also produce H₂S. The extent to which bacterial H₂S synthesis contributes to what is measured as colonic H₂S synthesis is not clear. When comparing conventional and germ-free mice we found no differences in colonic H₂S synthesis. Furthermore, we found that colonic H₂S synthesis is markedly increased when colonic tissue is inflamed, and, in proportion to the extent of inflammation, however fecal H₂S synthesis does not change. Finally, rats fed a B vitamin-deficient diet for 6 weeks exhibited significantly diminished colonic H₂S synthesis, but fecal H₂S synthesis was not different from that of rats on the control diet. Our results demonstrate that H₂S production by colonic bacteria does not contribute significantly to what we measure as colonic tissue H₂S production.</p> <p>In another study, the contributions of three enzymatic pathways to colonic H₂S synthesis were determined in tissues taken from healthy rats and rats with colitis.<strong> </strong>The ability of colonic tissue to inactivate H₂S was also determined. The majority of increased H₂S synthesis, in both healthy and inflamed tissue, was derived via a pyroxidal-5’-phosphate-independent pathway. Ulcerated mucosal tissue accounted for the greatest levels of H₂S synthesis, and the extent of granulocyte infiltration into the tissue did not appear to be a significant determinant of the levels of H₂S production. Inactivation of H₂S by colonic tissue occurred rapidly, but was significantly reduced in ulcerated colonic tissue from rats with colitis. Damage to colonic tissue appears to be the major stimulus for enhanced H₂S synthesis. Together, the increased production and decreased inactivation of H₂S may contribute to promoting resolution of inflammation and repair of damaged colonic tissue.</p> / Master of Science (MSc)